Effective case and incident note writing is fundamental to our documentation as care workers and service providers. Writing them effectively, clearly and concisely is essential for a range of reasons that allow for not only better delivery of services but also for legal reasons too.

For many, writing detailed and person-centred case notes and reporting can be challenging, even if you’ve been in the disability sector for some time. One of the most essential factors that we have to remember is that if “it isn’t written down it didn’t happen.” Always keep your language professional and clear, avoid slang or everyday abbreviations.

According to QCOSS (Queensland Council of Social Service), Queensland’s peak body for the social service sector:

“A good case note is one that not only contains the correct content, but considers how the information is framed, worded and used. For this reason, it is important to consider what you write in your case notes, how you write your case notes and what messages they might convey.”

The significance of detailed Case or Incident Notes:

Detailed and effective case notes are important for a number of reasons:

1. They provide an ongoing account of the participant’s journey.
2. Offers a detailed account of the needs, requirements, interventions and goals for the participant.
3. Ensures a continuation of care, even if health practitioners or support workers change.
4. Act as a legal document and record, offering protection for both the participant and the support workers.
5. Allows for better management of the needs or interventions required for the participant.

There are two important key factors that are important to good Case or Incident notes, and they involve being accurate and complete:

Accurate case notes provide a true and specific account of events,
decisions or actions that are taken or planned. They recognize that truth may sometimes be based
on perception.

There are a number of factors that are necessary to have effective notes:

Concise: Be as clear and detailed as possible without having extended and unnecessary information. Only relevant details should be given. Avoid using jargon or difficult language.

Participant-Centred: Keep the focus on the participant in your notes, detailing their views, feelings, and responses.

Fact-based Details: Always stick to the facts. The following details are crucial:

• What happened?
• Where did it happen?
• How did it happen?
• When did it happen?
• What was your response to the situation?
• How did you react?
• How did you deescalate the situation or calm down the participant?

Avoid giving your speculative or personal views on the situation. Only the facts of the incident are necessary. Avoid using diagnostic terms such as the participant was having a “depressive episode”, or she was “binge eating”. Instead use descriptive words such as she was “overeating”, she consumed “excessive amounts of foods”, or the participant appeared “sad and in a low mood.”

Be descriptive: Aside from explaining what happened, such as the participant was “agitated and angry”.” Knowing the participant explain why and how this situation occurred. For example, “the participant showed signs of being agitated and angry, by having rapid speech, swearing, and fidgeting possibly due to his upcoming court case.”

Show, Don’t Tell: Focus on ‘showing’, rather than ‘telling’. For example, don’t tell that Adam was ‘angry’. Show that Adam “was angry, as evident by his refusal to sit down and eat his lunch and pacing across the room.”

Centre the Participant: If the participant speaks or makes a statement, shares a concern or a goal, make sure you detail them and add them to the notes. Here are some examples:

• Mr. X verbalized that “My arm hurts.”
• Mr. X stared at staff and loudly stated that “I don’t want that medication, leave me alone.”

Case Notes must be Objective not Subjective:  Subjective notes involve your feelings and interpretations of what occurred. Subjective notes involve analysing why something happened and linking it to the actions and behaviours or responses of the participant. Here are some examples: 

• Subjective: I think Mr. X was not hungry today.
• Objective: Mr. X shook his head expressing he was not hungry when I offered him lunch at noon.
• Subjective: I think Ms. K was very tired today and did not want to do anything, probably because it’s close to her period.
• Objective: Ms. K was very tired today and did not want to do anything. Her mother mentioned that she had not slept very well last night.

Adhere to Timeliness: The fresher your memory the clearer the details and information you can provide. For legal reasons it is essential that you submit the case notes and incident reports as soon as possible. Do not wait for the next day or next week as your memory and recall is affected, and you possibly endanger the right of the participant to have all essential details and information submitted truthfully and in detail to management and Support Coordinators.

Maintain Professional Conduct: Keep the tone of your case notes and incident reports respectful and professional no matter how challenging and difficult the experience may have been. Remember, that the purpose of these notes are to better help support and manage participants who are vulnerable and may require further intervention and support. Centre the needs of the participant but do not be afraid to mention that their actions or responses caused distress or fear in you as a support worker.

Note Interventions: Note down what interventions were used, such as the police were called, or emergency services, management became involved and so on.

Challenges and Solutions:

At times, writing effective case or incident reports can be difficult due to time restrains such as needing to submit case notes right after your shift or incident reports within 24 hours. Additionally, sometimes an incident or situation can be very emotional and stressful so you may need some time to address the case or incident notes. Take a break if need be, and you can also ask a college or go to management to seek support or help in writing the notes more clearly.

Case notes are an essential and non-negotiable aspect of the work that we do as support workers, support coordinators and management. Regularly seeking feedback, asking for support, taking onboard feedback from management and attending training sessions are helpful to make you feel more confident in writing accurate and clear reports.